Change of perspective: impact of COVID-19 pandemic on axial spondyloarthritis-related web searches in Germany

Several conventional cross-sectional studies have investigated the impact of the coronavirus disease (COVID-19) pandemic on patients with axial spondyloarthritis (axSpA) and reached contrary results regarding health and well-being. As analysis of web search data already provided insights into public interest and unmet needs, this study aimed to examine axSpA-related web searches before and during COVID-19 pandemic to gain a different perspective on the impact of COVID-19 on this disease. The Google Ads Keyword Planner was used to generate axSpA-related keywords and their monthly number of searches between June 2018 and November 2021 in Germany. These keywords were qualitatively classified into seven categories. A total of 538 axSpA-related keywords were used for the analysis. The number of axSpA-related searches increased during COVID-19 pandemic (before: n = 1,525,010 vs. during: n = 1,848,300), particularly searches for symptoms, disease outcomes, and causes, while interest in disease management and diagnosis decreased. This study demonstrated a shift in public interest in axSpA during COVID-19 in Germany and highlights an urgent expansion of telemedicine to be prepared for exceptional situations such as a pandemic.

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that primarily affects the sacroiliac joints and the spine with inflammatory back pain, but can also include extra-articular manifestations like arthritis, enthesitis, psoriasis, iritis, and inflammatory bowel disease 1 .In March 2020, the World Health Organization declared a global pandemic caused by coronavirus disease (COVID-19) 2 , initiating a period of restrictions and multiple lockdowns, which could lead to new diseases or exacerbation of pre-existing diseases by reducing healthcare provider consultations and/or affecting mental health 3,4 .Ciuera et al. found no evidence of worsening disease activity in axSpA during the lockdown 5 , while others demonstrated that approximately 50% of axSpA patients reported worse health status and well-being than before the pandemic 6,7 .As analysing web search data on health topics can contribute to a better understanding of the interest and needs on a population-level 8,9 , this study aimed to examine the impact of the COVID-19 pandemic on axSpA in Germany by comparing axSpA-related web searches before and during the COVID-19 pandemic (cut-off: March 2020) in terms of search content.

Methods
In this retrospective analysis, the Google Ads Keyword Planner was used.Originally designed for marketing campaigns, its capability to provide monthly search volume data (i.e., monthly number of web searches) 8,10 .To ascertain the search volume in a specific area, search terms are input into the planner, language and geographical settings are set, and the program subsequently generates the most relevant keywords and phrases for the topic.For this study, six German search terms were entered to obtain related keywords and phrases with their monthly search volume between June 2018 and May 2022 in Germany (Fig. 1).The n = 543 identified keywords were individually checked for their relevance to axSpA, leading to the exclusion of five keywords which were unspecific and not clearly axSpA-associated (e.g., "back pain due to bacteria", "inflamed back muscle").The (1) terms and definition (e.g., "spondyloarthritis", "rheumatism Morbus Bechterew"), (2) disease outcomes (e.g., "life expectancy", "rheumatism back pain"), (3) disease management (e.g., "treatment", "experience reports"), ( 4) diagnosis (e.g., "Bechterew diagnosis", "HLA B27"), ( 5) symptoms (e.g., "rheumatism back symptoms"), ( 6) causes (e.g., "Morbus Bechterew causes"), and (7) COVID-19 vaccines.For recurring topics, categories were further classified into subcategories (e.g., physical manifestations).Each keyword was assigned to one (sub-)category only.Data was analysed descriptively.

Ethical approval
Institutional review board approval and informed consent were not necessary, because the study used publicly available data.

Discussion
In summary, the initial decrease in axSpA-related searches during the pandemic could be explained by the widespread attention regarding COVID-19 10 .However, overall axSpA-related searches increased during COVID-19, particularly for symptoms and physical manifestations, in addition to unknown factors not attributable to the pandemic, possibly due to the lack of medical appointments to clarify symptoms, provide medical information, and support for those affected.A reduction of consultations in German primary care during COVID-19 was previously found, mainly concerning manifestations of axSpA like back pain, gastrointestinal symptoms, fatigue, and pain therapy 1,3 , which may have led to the exacerbation of axSpA 7 .The higher interest in poor disease outcomes, like end stage and work disability, and in peer support may reflect general mental health impairments during lockdowns in the German population 4 , warranting further exploration.Additionally, the observed emphasis on these aspects may be attributed to the lack of information and comfort during restrictions resulting from the absence of in-person rheumatology appointments, which were rated as very important by the majority of axSpA patients surveyed in the United Kingdom 7 .Despite limitations, including the focus on Google users, exclusion of non-German speakers and potentially elderly, the impact of autocomplete, and reliance on monthly estimations, the study highlights the change in unmet needs.This emphasizes the urgency need to expand telemedicine concepts and increase patient confidence in them, to provide healthcare in exceptional situations, like a global pandemic.
time period was shortened by 6 months to ensure an equal number of months before and during COVID-19.The remaining keywords were inductively categorised into seven categories based on the study by Berr et al. 8 :

Figure 2 .
Figure 2. Time course of axSpA-related web searches from June 2018 to November 2021 in Germany.axSpA, axial spondyloarthritis.